Scleral buckling

3/6/2014
Scleral buckling
Dr. Ayman M. Khattab MD, FRCS
professor of Ophthalmology
Cairo University
Surgical Treatment
• Pneumatic retinopexy
• Scleral buckling.
• Primary pars plana vitrectomy.
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Scleral buckling
• Indications for scleral buckling.
SB is used to treat the majority of cases with
rhegmatogenous RD without significant PVR
( PVR less than C1)
Inferior retinal breaks
Retinal dialysis
Pediatric population
Scleral buckling
• Principles of scleral buckling.
1- close retinal breaks by apposing the RPE to the sensory
retina.
2- reduce dynamic vitreoretinal traction at sites of
vitreoretinal adhesion.
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Scleral buckling
• Surgical Technique
12345-
Peritomy & isolation of muscles.
Localization of breaks.
Treatment of retinal breaks.
Scleral buckling.
±Drainage of SRF ±air injection.
DACE technique
Scleral buckling
•
Surgical Technique
peritomy & isolation of muscles
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Scleral buckling
Surgical Technique
• Peritomy & isolation of muscles
Scleral buckling
Surgical Technique
• localization of breaks.
Precise localization of retinal breaks on the
sclera is crucial for accurate placement of the
buckle on the sclera.
Indirect ophthalmoscope & scleral localizer.
The position of each break is marked externally
on the sclera.
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Scleral buckling
Surgical Technique
• localization of breaks.
 small breaks are marked with single spot.
Large horseshoe tear → marked with 3 spots.
Retinal dialyses → mark the 2 ends and the
posterior extent of the mid point
Scleral buckling
Surgical Technique
• localization of breaks.
Difficult localization
Highly elevated retina
Posterior break
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Scleral buckling
Surgical Technique
• localization of breaks.
Highly elevated retina
The retinal break may appear because of parallax ,further
posterior than its true location when the detachment
flattens
 Scleral indentation is begun anteriorly in
the meridian of the break where the retina
is closest to the choroid then move posteriorly
 Presence of RPE changes underlying the
retinal break
 Drainage of SRF + intravitreal saline injection
Scleral buckling
•
Surgical Technique
localization of breaks.
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Scleral buckling
Surgical Technique
• Treatment of retinal breaks
Rationale for treatment :
is to form an adhesion
between the RPE & retina.
Methods :
1- cryotherapy
2- diathermy
3- photocoagulation
Scleral buckling
•
Surgical Technique
Treatment of retinal breaks
A-Cryotherapy
Mechanism
 Expansion of a high pressure gas (nitrous oxide) at the
tip of a probe generating temperature down to -89°C.
 The temp. effect is confined to the tip of the probe by
insulating sleeve
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Scleral buckling
Surgical Technique
• Treatment of retinal breaks
A-Cryotherapy
Goal of treatment




To surround all retinal breaks with 1-2 mm of contiguous treatment
without significant overlap.
Treatment should include both retina and choroid to create stronger
adhesion
The treatment endpoint is retinal whitening without ice crystal formation.
Allow to melt before removing the cryo probe.
Don’t freeze bare RPE in the bed of the retinal break … why?
Scleral buckling
Surgical Technique
• Treatment of retinal breaks
A-Cryotherapy
• A common mistake is to use the shaft, rather
than the tip, of the cryoprobe to indent the
sclera.
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Scleral buckling
Surgical Technique
• Scleral Buckling
Purpose to close retinal breaks & relieve
vitreoretinal traction.
Scleral buckling
Surgical Technique
• Scleral Buckling
Methods of buckling
1-exoplant→ the buckling material is sutured to the surface of
the sclera.
2-implant →
the buckling material is placed beneath scleral flaps
after lamellar scleral dissection
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Scleral buckling
Surgical Technique
• Scleral Buckling
Methods of buckling
Scleral buckling
Surgical Technique
• Scleral Buckling
Buckling materials
1- solid silicone rubber →tire, band ,strips
or wedges .
2- silicone sponge
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Scleral buckling
Surgical Technique
• Scleral Buckling
Type of scleral buckle( orientation )
1- Segmental
 radial placed at right angle to the limbus
 Circumferential placed parallel to the
limbus
2- Encircling
placed around the entire circumference of the
globe to create 360° buckle
Scleral buckling
Surgical Technique
• Scleral Buckling
Type of scleral buckle
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Scleral buckling
Surgical Technique
• The height of the buckle is determined by
The greater the diameter of the buckle, the
greater height
The greater the separation of sutures, the
higher the buckle
 Low buckle→ 2 mm wider than the buckle size
 High buckle→ 3-4 mm wider than the buckle size
The tighter the sutures over the buckle the
greater the height
The lower of the IOP, the higher the buckle
Scleral buckling
Surgical Technique
• Buckle sutures
 The sutures are arranged in mattress
fashion.
 One-half of the scleral thickness.
 Intrasclearal course 4-5 mm long.
 Parallel to the long axis of buckle.
 The tip of the needle should be
visualized at all times as it is passed
through the sclera.
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Scleral buckling
Surgical Technique
• Buckle sutures
Type of needle»» spatulated 3/8 of circle
Type of suture »» 5/0 Ethibond
polybutylate Coated braided polyester
Scleral buckling
Surgical Technique
• Buckle size
The buckle must be of sufficient width to
leave a safety margin of 1 mm of retina
between the break and the edge of the
buckle
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Scleral buckling
Surgical Technique
• Buckle size
The width of the buckle is mainly
determined by:
The size of the retinal break to be closed
The distance separating multiple breaks if present
Scleral buckling
Surgical Technique
• Scleral Buckling
indications
Radial buckle
1-large flap tear
2-relatively posterior tear.
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Scleral buckling
Surgical Technique
• Scleral Buckling
Radial buckle
3 mm
1 mm
53mm
mm
7 5mm
mm
5 mm
7.5mm
mm
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Scleral buckling
Surgical Technique
• Scleral Buckling
Radial buckle
Scleral buckling
Surgical Technique
• Scleral Buckling
indications
Circumferential buckle
1-long retinal tear eg retinal dialysis
2-multiple breaks close together.
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Scleral buckling
Surgical Technique
• Scleral Buckling
technique
Circumferential buckle.
Scleral buckling
Surgical Technique
• Scleral Buckling
Encircling buckle
1-retinal breaks involving 3 or more quadrants
2-diffuse retinal pathology eg extensive lattice
degeneration
3- to support local buckle
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Scleral buckling
Surgical Technique
• Scleral Buckling
Encircling buckle.
Scleral buckling
Surgical Technique
• Drainage of subretinal fluid (SRF)
Rationale
1-To diminish the intraocular volume so as to allow
elevation of the buckle without elevation of IOP.
2-To allow the retina to settle on elevated buckle
by removing fluid from the subretinal space.
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Scleral buckling
Surgical Technique
• Drainage of subretinal fluid (SRF)
When
Indications
1-bullous RD
Where
(when)
How
to place the retinal break in apposition to
the buckle
2-inferior retinal break :
 inferior breaks tend to settle less readily on the
buckle
 inferior breaks are less effectively managed
postoperatively with air injection.
Scleral buckling
Surgical Technique
• Drainage of subretinal fluid (SRF)
Indications
3- chronic RD
( old standing RD & retinoschesis with RD)
viscous SRF→ delayed absorption.
4-poor RPE function as in high myopia → delayed
absorption.
5- the need for internal tamponade.
6- danger of high IOP. Open angle glaucoma,recent
cat. Surgery, poor ocular perfusion, thin sclera.
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3/6/2014
Scleral buckling
Surgical Technique
• Drainage of subretinal fluid (SRF)
Selection of drainage site (where)
 Done in an area where there is sufficient SRF.
 Drainage just above & or below the horizontal meridian
→ the choroid is less vascular → nasal quadrant may be
preferred
why ? .
 Drainage is avoided in areas treated with cryotherapy →
because choroidal congestion induced by cryo
predispose to hemorrhage.
→
Scleral buckling
Surgical Technique
• Drainage of subretinal fluid (SRF)
Technique (How)
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Scleral buckling
Surgical Technique
• Drainage of subretinal fluid (SRF)
Technique
Scleral buckling
Surgical Technique
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Thank You
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